Crosswalk: Exception Request Template

Number

Form

1

Exception Request Template

Revised the drop-down list of specialty types to reflect proposed changes in CMS-4205-F, outpatient behavioral health

Part I: Exception Information: Specialty

CMS-4205-F finalizes the addition of the facility type- outpatient behavioral health

2

Exception Request Template

Added additional guidance for facility based I-SNP's ability to use the inability to contract reason as a valid exception request rationale

Part V: Table of Non-Contracted Providers

CMS-4205-F adds facility based I-SNPs the ability to request an exception to the network adequacy criteria based on inability to contract.

Change

Current Location

Reason